The New Directions Autism Resource Program provides members with assistance in managing the Autism Spectrum Disorder (ASD) benefit provided by their health care policy. Care Managers, specially trained in treating ASD, assist families through the process of obtaining a diagnosis and authorizing treatment.
To take advantage of your ASD benefit, contact a New Directions Autism Resource Program care manager at 877-563-9347. For questions about your insurance plan, including services, exclusions and your payment responsibilities, please contact your health plan.
ASD, often known as autism, is a developmental disability. All children with ASD have challenges in their social interactions, verbal and nonverbal communications, and behavior skills. They may repeat their actions or have ultra-sensitive reactions to smells, tastes or textures. There is a broad range of abilities among people with ASD; some are gifted while others are severely cognitively challenged. Some need more structure than others to get through the day. ASD is not characterized by how a person looks. Individuals with ASD exhibit symptoms that typically begin in early childhood.
To determine if your child has ASD, a licensed health care professional with special expertise in childhood development will coordinate a comprehensive diagnostic evaluation. An evaluation team often has a physician, psychologist, speech therapist, and occupational therapist component. During the diagnostic evaluation, these qualified professionals will review your child’s developmental and medical history, behavioral and cognitive evaluation, current medical condition, neurological evaluation, autism specific assessments, and other information that may be required by state mandate.
State laws often identify which types of provider can make a diagnosis of ASD for it to be covered as an insurance benefit. Pediatricians, psychiatrists, licensed clinical psychologists, or child neurologists are typically listed. To find a qualified provider who can help with a comprehensive diagnostic evaluation for your child, please call the New Directions Autism Resource Program at 877-563-9347.
Though there are many methods available to treat people with ASD, applied behavior analysis (ABA) is currently the most widely recognized as a safe and generally effective treatment for autism, endorsed by many state and federal agencies, including the U.S. Surgeon General. Clinical research shows that ABA techniques improve communication, social relationships, self-care, play and school.
Behavior analysis is the scientific study of learning and behavior. Behavior analysis focuses on the principles that explain how learning takes places most efficiently and effectively. Applied Behavior Analysis (ABA) is the use of these principles and strategies used to shape, change and improve behavior. The purpose of the treatment is to bridge the gap between a person’s current chronological age and measured developmental age so they can function effectively with others in their natural environment.
Typically, a Board Certified Behavior Analyst (BCBA) oversees ABA treatment. Registered Behavioral Technicians (RBTs) or “Line Therapists” provide the majority of the ABA treatment under the direction and supervision of the BCBA.
For information about the ABA services your health insurance plan covers, refer to your health plan coverage handbook.
If ABA services are covered, they will address ASD core categories. Such services include social communication deficits, social interaction deficits, repetitive behaviors, and restrictive behaviors.
Services that replicate or duplicate federal or state mandated programs available through public education resources are typically not covered by health insurance benefits.
Yes, treatment services need to be pre-authorized by New Directions before your health plan benefits will pay for them.
Your Health Plan’s website has a listing for ASD treatment providers. If you are not in the same state as your Health Plan, please choose the out-of-state provider directory.
We know finding the right provider for your child can be challenging. Your New Directions’ Autism Resource Program care manager is available to help you find providers in your area at 877-563-9347. Your care manager can also tell you if your policy covers non-network ABA providers.
Before your child can begin ABA treatment, New Directions confirms three conditions are met:
- You have an active benefit.
- Your child has received a diagnosis of ASD and recommendation for ABA treatment.
- You have chosen an eligible ABA service provider and notified New Directions of your choice.
New Directions will then issue an authorization to the ABA provider for an initial ABA treatment assessment. An assessment determines the specific learning areas to be targeted and proposes the intensity of treatment services proposed for your child.
To conduct the initial assessment, the ABA provider will meet with you and your child for an in-depth evaluation. This evaluation will include a review of the completed comprehensive diagnostic evaluation, previous treatment attempts, current medical and behavioral treatments, and any academic education- based support plans. Based upon the needs and deficits in function identified, your ABA provider will create a proposed treatment plan. Treatment plans include:
- Baseline information for your child’s current functioning for all the core deficits of ASD
- Short-term goals to be accomplished over the next six months
- Long-term treatment goals to be completed over the course of treatment
- Schedule of treatment hours per day for each day of the week your child is in therapy
- Location your child will receive services (home, clinic, etc.)
- Anticipated barriers to progress and how they will be addressed
- Parent training expectations and goals
- Referrals to appropriate professional and community supports
- Collaboration with other medical and behavioral treatment providers
- Discharge or transition plan that outlines discharge criteria and transitional services once ABA treatment is complete
Your ABA provider will submit the proposed treatment plan to New Directions for a benefit coverage determination. New Directions will review the proposed plan to verify that the requested services are medically necessary. New Directions will complete our review within 15 days of receiving all required information. We then notify your ABA provider of the results of our review by letter or fax. We’ll send you a letter with the same information.
After your child’s treatment plan is authorized for health plan benefit coverage, you may make your child’s first appointment.
ABA care is typically authorized for a six-month period. Since ABA services are typically provided for longer than six months, and may proceed for a number of years, your child may need treatment beyond the end date of an ABA authorization. Every six months, your provider will review the previous treatment plan, record current progress, and develop additional goals to be completed over the next six-month review period. A psychological testing instrument called the Vineland Adaptive Behavioral Scale will be requested within 45 days prior to an annual authorization treatment request. Standardized psychological testing like the Vineland is used to help show what developmental progress your child is making compared with peers their same age. Depending on your child’s progress, other psychological testing may also be requested. Once the provider has completed the review, he or she will submit a new authorization for treatment request to New Directions.
Once New Directions receives the new treatment request from your provider, we will review it and approve additional treatment coverage so long as the treatment plan meets medical necessity criteria for ongoing care.
Your New Directions Autism Resource Program care manager will reach out to you periodically between review cycles to assist with the process.
For any further information about the ongoing authorization process or with help finding a contracting psychologist who can administer a Vineland Adaptive Behavioral Scale or other psychological test, please contact your Autism Resource Program care manager at 877-563-9347.
ABA services can be provided in the home, a treatment center, or in the community. Please review your health plan’s coverage handbook because some plans have specific exclusions about where ABA services can be provided.
New Directions’ care management staff reviews each request for services based on the coverage criteria in effect for your health plan. These coverage criteria are located on the New Directions website under Autism. New Directions uses the criteria to determine if further services will be covered under your health plan benefit. Services must be considered “medically necessary” according to the coverage criteria in order to be covered.
New Directions reviews the coverage criteria annually or more often as new findings on ASD treatment are released into the professional community. During quarterly Provider Advisory Committee meetings, New Directions receives input from ABA service providers on any changes proposed to the coverage criteria.
New Directions will work with your provider to determine the appropriate level of care and health care services for your child.
Please note: The treating provider, in collaboration with you, is responsible for any treatment decisions regarding the initiation or continuation of a specific service. New Directions does not make any treatment decisions regarding your child’s care. We make a benefit coverage determination for services that may be reimbursable under your health plan coverage.
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Additional ABA services can be approved after a child is discharged so long as he or she falls within the age restrictions outlined in your health insurance plan. If a treatment request is submitted after a child has been discharged, New Directions will review it in accordance with our review process described above.
New Directions’ Autism Resource program provides authorizations for ABA services only. Your Autism Resource Program care manager can help you with referrals to other needed medical and behavioral health services. Should you have questions about medical service coverage, please contact the health plan customer service number on the back of your insurance card.
Your health plan benefit determines any age restrictions on reimbursement of ABA therapy. For coverage guidelines, please refer to the customer service phone number on your insurance card.
As you and your child progress through treatment, it may become appropriate to access different resources. There are multiple types of resources that may be helpful as your child transitions through life. These types of resources may include: general information, different types of therapies and educational resources. Below are a few national resources and organizations that may be able to offer assistance.
National Autism Specific Organizations:
National Educational Resources:
National Resources Related to Disabilities:
Aberrant/Maladaptive Behavior: Any behavior that can obstruct the way an individual learns or experiences the environment. Also referred to as problem behaviors.
Antecedents: The event that occurs before a behavior.
Baseline Data: objective and quantitative measures of the percentage, frequency or intensity and duration of skill/behavior prior to intervention.
Behaviors: Any activity of an individual that can be observed and measured.
BIP (Behavior Intervention Plan): Usually completed after a FBA is completed. A BIP should include the target behavior, function(s) of behavior, operational definition, antecedent interventions, replacement behaviors, and consequence interventions.
Consequence: The event that occurs after a behavior.
Core deficits of Autism: persistent deficits in social communication and social interaction across multiple contexts AND, restricted, repetitive patterns of behavior, interests, and activities
Chaining: Linking smaller, individual behaviors to form a more complex chain of behaviors. Chaining procedures can be performed as a forward chain (where complex behaviors are taught with the first step, then the rest of the responses are prompted) or backwards chaining (where complex behaviors are prompted and the individual completes the last step). Often used in conjunction with a task analysis.
Custodial Treatment: Non-skilled, personal care. Examples include:
- Help with activities of daily living, such as bathing, dressing, eating, getting in or out of a bed or chair, moving around, using the bathroom, preparing special diets, and taking medications
- Care designed for maintaining the safety of the member or anyone else
- Care with the sole purpose of maintaining and monitoring an established treatment program
DRI (Differential Reinforcement of Incompatible Behavior): Behavior that is incompatible with the problem (or unwanted behavior) is reinforced. An example would be reinforcing a child putting his hands in his pocket instead of him engaging in finger gesture stereotypy.
DRO (Differential Reinforcement of Other Behavior): Behavior is reinforced in the absence of the problem behavior. For example, the individual who is not engaging in the problem behavior would be given reinforcement.
Duration: How long a behavior occurs, from start to finish.
Echoic: Where a person’s verbal language is duplicated or copied by another person.
Errorless Learning: A teaching procedure where the individual is automatically prompted so that they do not engage in an error, and can access reinforcement for engaging in the target behavior.
Extinction: Withholding reinforcement for the previously reinforced behavior, lowering the rate of the target behavior to an eventual absence.
Fading: The gradual removal of prompts or stimuli in order to obtain an independent response.
Fluency: How quickly the individual can exhibit a behavior after the stimuli is presented.
Frequency: The number of times that a certain behavior occurs
FCT (Functional Communication Training): Often displayed as a type of DRA, FCT occurs when the individual is given the opportunity to communicate his/her desire instead of engaging in a problem behavior.
Functional Analysis: Empirically supported process of making systematic changes to the environment to evaluate the effects of the four testing conditions of play (control), contingent attention, contingent escape and the alone condition, on the target behavior, which allows the practitioner to determine the antecedents and consequences maintaining the behavior.
Generalization: Skills acquired in one setting are applied to many contexts, stimuli, materials, people, and/or settings to be practical, useful, and functional for the individual. Generalized behavior change involves systematic planning, and needs to be a central part of every intervention and every parent training strategy.
Interpersonal Care: Interventions that do not diagnose or treat a disease, and that provide either improved communication between individuals, or a social interaction replacement.
Inter-Response Time: The time between the end of one response to the start of the next response.
Intervention: A change in the individual’s environment that is meant to manipulate the target behavior.
Intraverbal: A type of verbal behavior in which the desired answer or response is not observed. No point-to-point correlation. This can involve social conversations, fill in the blanks, and other verbal behavior that doesn’t relate to something that can be seen.
Latency: The measurement from the presentation of a stimuli until the engagement in the desired behavior.
Maintenance: The ability for the individual to display a skill previously taught without additional training over time.
Mand: Often referred to as a request. An opportunity where an individual will ask for an item or activity.
Mastery Criteria: Objectively and quantitatively stated percentage, frequency or intensity and duration in which a member must display skill/behavior to be considered an acquired skill/behavior.
Motivating Operation: Also referred to as setting event. This is something occurs before the behavior that has a direct impact on the occurrence of a behavior. For example, if water is with-held from a person, it could make the person thirsty.
Neurological Evaluation: This needs to be completed and documented on every member by a licensed physician as part of the diagnostic evaluation. Any significant abnormalities on the minimal elements of an exam should trigger a referral to a neurologist to perform comprehensive testing to assess neurological abnormalities. Minimal elements include:
- Evaluation of Cranial nerves I-XII
- Evaluation of all four extremities, to include motor, sensory and reflex testing
- Evaluation of coordination
- Evaluation of facial and/or somatic dysmorphism
- Evaluation of seizures or seizure like activity
Paraprofessional Care: Services provided by unlicensed persons to help maintain behavior programs designed to allow inclusion of members in structured programs or to support independent living goals except as identified in state mandates or benefit provisions.
Premack Principle: Usually displayed as “First ____, then ___”. Using an undesirable item/activity to work towards the highly preferred activity/item as a reinforcement.
Probe: A collection of data where a BCBA will probe behavior by seeing if the individual will engage in the target behavior in one instance.
Problem Behavior: Also known as aberrant or maladaptive behaviors. Any behavior that impedes an individual to learn and interact with his environment.
Punishment: Any consequence that has an impact on the target behavior and lowers the rate of occurrence.
Reinforcement: Any consequence that has an impact that increases the rate of the target behavior.
Respite Care: Care that provides respite for the individual’s family or persons caring for the individual.
Shaping: The act of teaching new behaviors to look more like the desired target behavior.
Standardized Assessments: The listed assessments are not meant to be exhaustive, but serve as a general guideline to measure intelligence, adaptive behaviors or provide diagnostic assessment.
Stimulus: Any antecedent event that proceeds the occurrence of a behavior.
Stereotypy: Also referred to as “stimming”. An individual with ASD will often engage in self-stimulatory or repetitive behaviors that are referred to as stereotypy in ABA.
Tact: Often considered a label. An individual will tact items when giving it a name, category or function.
Task Analysis: The break-down of a complex behavior into multiple smaller, and more manageable teaching steps. This is often performed when chaining behaviors.
Topography: The form in which a behavior takes; what the behavior looks like.
Cooper J., Heron T.E., Heward W.L. (2007). Applied Behavior Analysis. Pearson Prentice Hall. 2nd Edition.
New Directions. (2017) Medical Policy: Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder. 25 pages.